Breast cancer is a very difficult journey. In the
beginning, there is so much information being thrown at the
patient at once, and it is never easy to make the big
surgical decisions in the face of breast cancer. And
all the information is overwhelming and it comes in all
directions, from physicians to family and friends. One of the first decisions you will be presented with is
what type of surgery you will need. Depending on the
size, location, and characteristics of your tumor, your
breast surgeon can present you with several surgical
options.
The range of emotions one goes through include anger to
confusion, so it is important that you know your risk
factors and what is the best course of treatment for your
case.
Fear -
about going through surgery or losing a
breast
Anger
- about getting cancer in the first place
Sadness
- about losing a part of your body
Breast cancer patients find themselves thrown into the war
of fighting this disease with a team of physicians, each one
having an equally important role in you becoming a survivor.
The surgical advances in the last couple of decades have
been phenomenal with finding the best cutting edge
technology to perform the latest techniques in breast
reconstruction. Medical science has advanced so much
with fighting this disease, with their commitment to find a
cure - patients now have better odds of winning over cancer.
Losing a breast in any capacity is something no woman wants
to go through and it can tend to overshadow the concern for
your health. The most important goal is to live a long
life "cancer free"; however, just as important is holding on
to your femininity. If your plastic surgeon recommends
a mastectomy, many women can have immediate reconstruction! The main goal of breast reconstruction is to give the woman
a sense of feeling whole again. There are no right or
wrong answers with what is going to be right for you.
The standard of care for most mastectomy patients are for
immediate breast reconstruction. This surgery is done
at the time of the mastectomy, so the patient can wake up
with a lesser deformity and know that she is on the
reconstruction path. The psychological and aesthetic
benefits of having this done at the time of mastectomy
outweighs delaying the reconstruction. The drawbacks
of having this surgery done at the time of the mastectomy is
that it is a longer surgery and recovery, and if the patient
needs radiation then this alone can compromise the
reconstructed breast.
Patients facing breast reconstruction
are concerned how the new breast will be in terms of shape, size,
symmetry and of course,
scarring. Due to the surgery,
reconstructed breasts can sometimes appear flatter, more round, or
have less projection than a patient's natural breast. A lot
depends on whether your breast will be reconstructed with your own
tissue or an implant.
From a surgical perspective,
bilateral reconstruction presents a better chance for symmetry,
because the surgeon is starting with a clean slate. Unilateral
reconstruction is harder, because it tends to be more difficult to
match the natural droop of the opposite breast.
Restoring the breast is not
considered cosmetic surgery - this is plastic reconstructive
surgery. This surgery is performed to restore a woman's
anatomy and symmetry that she may have lost after a mastectomy.
Breast reconstruction not only improves your physical appearance but
has psychological benefits as well.
Breast
Reconstruction involves a surgeon forming a breast mount by using
either an implant or actual tissue from the patient located from the
abdomen, back or buttocks area. The choice of breast reconstruction
type will depend on the patient’s body type, age and cancer
treatment.
Breast reconstruction takes more than one surgery,
including:
One of the options of
reconstruction from breast cancer; is using breast implants. Almost one half
of all the breast reconstructive procedures involves breast implants. Some
patients are able to have the mastectomy and the placement of breast implants
all done at once, providing that your chest wall is not too tight.
The pectoralis muscle, which
the implant will have to be placed behind, can sometimes be very strong and
thick. The thicker the muscle is, the harder it is going to be to place an
implant immediately. If this is the case, the plastic surgeon will insert a
balloon-like tissue expander to stretch the tissue and muscle wall to gradually
accommodate an implant.
Breast Reconstruction with an implant placed
completely behind the muscle
Having expanders will mean
that the patient will go in regularly once a week for a period of anywhere from
six to eight weeks, to have the expanders filled with injections of saline
solution. There is a port that the plastic surgeon will use (normally near the
arm pit area) that the injections of the saline will go to fill the expander to
prepare it for the actual implant surgery.
This procedure is much less
invasive that autologous reconstruction, and normally can be a choice for most
breast cancer patients. However, if the patient will need
radiation therapy
then they are not a good candidate for reconstruction with implants. The
surgery time for breast reconstruction with an implant is a much shorter than
other methods, and may not require as much hospital time, providing it can be
done at the time of the mastectomy.
If the patient elects to only
reconstruct one breast with an implant, the chances are the implanted side will
appear different. The shape of a breast reconstructed with an implant is going
to have a different shape and feel to it. This is because as a woman ages her
natural breast tissue changes shape. This procedure, if you are only having one
breast reconstructed is better for women with small to medium sized breasts with
little to no sagging. If a patient decides to have this done, then the surgeon
can also either augment the other side or perform a reduction, so that the size
will be more symmetrical.
As with
breast augmentation,
implants offered for reconstruction are two specific types – either saline or
silicone. The use of silicone in reconstruction can sometimes
yield a much better result rather than saline, as the incidence of rippling is
not as much with the cohesive gel implants.
Breast reconstruction sometimes requires the use of a tissue expander which will
be placed beneath the skin and
chest muscle. The expander is a saline filled device with a valve that
will allow the volume to be added over a period of several weeks or months.
Some expanders have a
separate injection port that is placed under the skin of the axilla or
armpit area and is connected to the tissue expander body via a thin silicone
rubber tube.
Other tissue expanders
have an internal or integrated injection port built directly into the
expander itself. Incorporating the injection port into the expander helps
in eliminating the risk of separation of the injection port from its
connecting tubing. This problem can cause the tissue expander to leak and
to deflate and that requires additional surgery to correct.
Some plastic surgeons
support the use of a post operative adjustable breast implant as an
alternative to placement of a tissue expander followed by a conventional
breast implant. This adjustable implant resembles a saline filled breast
implant. It comes with a silicone rubber tube and remote port. Although
somewhat similar in functionality as the expander, the benefit of this
device is that there would be no further surgery. The surgeon closes off
the adjustable breast implant port, removes the tubing and the port and
stitches up the tiny incision.
Your plastic surgeon will want to expand the
skin until the reconstructed side is about 10 percent larger than the
opposite breast to compensate for the fact that the expanded tissues can shrink
or recoil slightly after the expander is removed. Enlarging the
reconstructed side larger also helps with trying to prevent capsular contracture. The shrinkage is not a problem if the patient is able to have immediate
reconstruction with an implant in place.
There will be some discomfort
with having the expanders, as the plastic surgeon will normally put in more ccs
of saline than the actual size of the implant he or she might use. There
usually is not a lot of pain associated with this, however.
After the patient has reached
the desired size which is done with repeated office visits over a period of
several months, the skin muscle envelope is slowly stretched to accommodate the
new implant size.
The last step of this process
is an out-patient procedure done in a surgery center or hospital where the
expander is removed and replaced with a permanent implant. Once the implant is
in place, the size of the reconstructed breast cannot be changed without a
surgical replacement.
Most implants will need to be
replaced at some point eventually, because breast implants are
not life time devices. Scarring and Capsular
Contracture
are the most common complications with using implants.
This procedure
entails a series of visits to your plastic surgeon – a balloon like
device or a silicone shell implant previously inserted into the
breast area is repeatedly filled with saline over a period of time.
This process slowly stretches the tissue until the desired breast
mound size is achieved. Once tissue expansion is achieved, the
implant valve is sealed shut. Or another implant is used to give the
desired shape and size of the breast mound, which is a more
permanent method. Implant techniques are usually shorter procedures
that require the least amount of recovery and downtime.
There are some women
who will not need to have a tissue expander at all, in which the
surgeon will precede directly to the permanent implant surgery.
Because breast implants are not lifetime devices, the patient will
be facing subsequent surgeries to replace these devices as they age.
Implants are available
in
saline and silicone,
and come
in a variety of shapes (round
implant or
anatomical shape implants), sizes, and
textures.
Some women are fortunate in
order not to need to have tissue expansion and are able to have the saline or
the silicone implant inserted immediately after mastectomy. This depends on
whether the size of the skin-muscle envelope is large enough to accommodate the
implant.
The surgeon performs the
implant based reconstruction by creating a pocket or cavity so the tissue
expander or the implant can be placed beneath the pectoral muscle. Blood
transfusions are not necessary with this procedure. Creating the pocket under
the muscle will cause some pain in the breast area for a few days after
surgery. The pain is normally controlled with no problem with oral narcotic
pain medication.
Women who are thin and athletic and are in need of breast reconstruction due to
a mastectomy sometimes are faced with the breast implant rippling or the edges
of the prosthesis showing because they do not have much tissue left.
Plastic surgeons are finding that the hip area or the "love handle area" can be
an adequate source of body fat for "grafting" over the implant to help disguise
the implant.
When implants are not used, flap reconstruction is another option. The
TRAM Flap
is the most commonly used procedure to help reconstruct breast tissue and skin
from the abdominal area. If the patient is thin and athletic - most women
will not have enough tissue in that area, however; they are finding more excess
fatty tissue in the space between the hip and the waist called "love handles".
Implants that are used in
reconstruction will not interfere with diagnosing a recurrence of cancer in that
breast. Most surgeons and oncologist do not do mammograms of a reconstructed
breast, simply because there is no breast tissue left. The implants are right
against the chest wall and any recurrence is likely to be on the skin, so it is
unlikely that an implant would mask any recurrence.
ADVANTAGES OF BREAST
RECONSTRUCTION USING IMPLANTS:
Same mastectomy incision
is used to insert the tissue expander and or implants, no additional scars
on the breast
Radiation increases the risk
of Capsular Contracture,
and also has a tendency to compromise the existing tissue that is left on the
chest wall from the mastectomy that was performed. Radiation therapy often
leaves the skin and underlying tissue discolored or damaged. Most surgeons tend
to recommend breast reconstruction with a tissue flap instead if the patient
needs Radiation Therapy.
